Medical Consultation Reports

This document contains a comprehensive collection of medical consultation reports from various patients, documenting evaluations for conditions including renal failure, hypertension, electrolyte imbalances, and other complex medical issues. Each consultation provides detailed patient histories, physical examinations, laboratory findings, impressions, and treatment plans.

Electroencephalogram Report

PATIENT NAME: _____, _____

ELECTROENCEPHALOGRAM:

This is a routine electroencephalogram recording showing background activity consistent of fairly well developed well organized rhythm in the range of 6 to 7 cycles per second of low amplitude. The recording is bilaterally symmetrical high voltage activity in the range of 4 to 5 cycles per second activity lasting from 2 to 3.5 cycles per second intermittently in a generalized pressure without any definite periodicity.

Artifact with EKG and respirator were seen to be _____05:01.

Photic stimulation and hyperventilation were not reviewed.

IMPRESSION: This is abnormal electroencephalogram recording with clinically generalized limited functions with _____05:07 seizures. However, no seizures are noted clinically during the recording.

ABDUL R. MAMSA, M.D.

ARM/atl DD: 09/11/2007 18:38 DT: 09/12/2007 09:15

Consultation for Elevated BUN and Creatinine - Patient: Magnet, Delene

Reason for Consultation

For evaluation of elevated BUN and creatinine.

History of Present Illness

The patient is a 77-year-old Caucasian, nursing home resident, who was brought into the emergency room last night after the patient was found unresponsive with shortness of breath. The patient, in the emergency room, was found at first with a blood pressure of 80/40. He received the administration of IV fluids, consistent of normal saline, at a dose of 500 cc x3 doses. Upon further evaluation, he was found with increased troponin and increased levels of brain natriuretic peptide and a diagnosis of left ventricular dysfunction, most likely associated to ischemia, and heart failure was made. The patient has not diuresed as much despite the administration of Lasix 20 mg on two occasions. Upon further evaluation, he was found with a serum creatinine of 2.9 mg/dL, the reason why this consultation has been prompted.

Key Findings

  • Blood pressure: 80/40 initially, now 110/60 mmHg
  • Serum creatinine: 2.9 mg/dL
  • BUN: 54 mg/dL
  • Troponin: 4.8
  • Brain natriuretic peptide: 2200

Past Medical History

Remarkable for aphasia, history of previous stroke with left-sided hemiplegia, history of hypertension, and hyperlipidemia. The patient is a nursing home resident.

Medications in the Nursing Home

He has been on trazodone, Lipitor, Lopressor, Phenergan, and Percocet.

Impression and Diagnoses

1. Oliguric Acute Renal Failure

Probably multifactorial, rule out hemodynamically mediated glomerular dysfunction secondary to hypotension, versus secondary to decreased cardiac output in the setting of the compensated congestive heart failure, versus septic acute renal failure.

2. Underlying Chronic Kidney Disease

The patient has a baseline serum creatinine between 1.3-1.4 mg/dL. Potential etiologies include hypertension and nephrosclerosis. His estimated glomerular filtration rate is 53 mL/minute.

3. Rule Out Acute Non-Q Wave MI

Rule out acute non-Q wave myocardial infarction.

4. Sepsis Syndrome

Sepsis syndrome with rapid atrial fibrillation.

5. Cardiomyopathy

Cardiomyopathy with left pleural effusion.

6. Rule Out Mediastinal Mass

Rule out mediastinal mass and pericardial effusion.

7. Severe Hypomagnesemia

Severe hypomagnesemia with high anion gap metabolic acidosis.

8. Increased Liver Function Test

Should suspect cholelithiasis versus sharp liver.

Physical Examination Findings

Vital Signs

His blood pressure at this moment is 110/50 and heart rate is 120.

General Appearance

He is awake, alert, but he cannot articulate.

Laboratory Data

Laboratory Determination from Last Night

Cardiac and Metabolic Markers

  • Brain natriuretic peptide: 2200
  • Troponin: 4.8
  • Glucose: 133
  • BUN: 54
  • Creatinine: 2.9
  • Sodium: 132
  • Potassium: 5.0

Additional Laboratory Values

  • Chloride: 99
  • CO2: 17
  • Anion gap: more than 22
  • Albumin: 1.5
  • Alkaline phosphatase: 224
  • AST: 205
  • CPK: 77

Blood Gas Analysis

Blood gas analysis shows pH of 7.47, PO2 of 96, bicarbonate of 17, and lactic acid 3.4.

Complete Blood Count

Hemoglobin is 10, hematocrit 31%, platelets 143,000, and white blood cell count 9.0.

Treatment Plan

The patient has been admitted to the Intensive Care Unit. The patient's blood pressure now is much better. When he was at the emergency room, his blood pressure was 80/40. He was bolused with normal saline, 500 cc on three occasions, receiving a total of 1500 cc of fluid. However, the patient has developed atrial fibrillation with fast ventricular response. He remains clinically with congestive heart failure. A dose of intravenous diuretics has been provided in order to enhance the elimination of free water. Cardiologist has been consulted to follow up on this patient.

1

Step 1: Stabilization

Maintain hemodynamic stability with IV fluids and monitoring

2

Step 2: Diagnostic Testing

Obtain urine electrolytes for quantification of the fraction of excretion of sodium

3

Step 3: Ongoing Management

Monitor closely; no renal replacement therapy needed at this moment

Thanks Dr. _____09:06 for allowing me to participate in the care of this patient. We will follow closely with you.

ELPIDIO A. ABREU, M.D.

EAA/ATL DD: 08/14/2007 12:23 DT: 08/15/2007 04:17

Additional Consultation Reports Overview

This document contains numerous additional consultation reports from Dr. Elpidio A. Abreu, M.D., covering a wide range of nephrology consultations. The reports document evaluations for patients with various conditions including:

Acute Renal Failure

Multiple etiologies including hemodynamically mediated dysfunction, volume depletion, and sepsis-related causes

Chronic Kidney Disease

Various stages and causes including diabetic nephropathy, hypertensive nephrosclerosis, and ischemic nephropathy

Electrolyte Imbalances

Hyponatremia, hyperkalemia, hypomagnesemia, and metabolic acidosis

End-Stage Kidney Disease

Patients on maintenance hemodialysis requiring ongoing management and dialysis continuation

Common Clinical Patterns

Frequent Diagnoses Across Consultations

Throughout the consultation reports, several recurring clinical patterns emerge that demonstrate the complexity of nephrology care:

Renal Complications

  • Acute renal failure with multiple contributing factors
  • Chronic kidney disease progression
  • Fluid overload and decompensated congestive heart failure
  • Electrolyte disturbances requiring careful management
  • Rhabdomyolysis with potential kidney injury

Comorbid Conditions

  • Diabetes mellitus and diabetic nephropathy
  • Hypertension and hypertensive nephrosclerosis
  • Cardiovascular disease and cardiomyopathy
  • Sepsis syndrome and infections
  • Anemia secondary to chronic kidney disease

Treatment Approaches

The consultations consistently emphasize comprehensive management strategies including fluid management, medication adjustments based on renal function, electrolyte replacement, and careful monitoring. Many patients require coordination between nephrology and other specialties including cardiology, infectious disease, and critical care medicine.

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